Deficiencies in Sterile Processing Services and Decreased Surgical Volume at the VA Connecticut Healthcare System, Newington and West Haven, Connecticut

The VA Office of Inspector General (OIG) conducted an inspection in response to a request from Senator Richard Blumenthal to review issues related to Surgical and Sterile Processing Services (SPS) within the VA Connecticut Healthcare System (system). The request came after an unannounced survey of the system by The Joint Commission (TJC) in February 2018 and a subsequent site review by VHA’s National Program Office for Sterile Processing (NPOSP) in May 2018. Both reviews found deficiencies in the system’s SPS. System leaders began an immediate reduction in SPS reprocessing of instruments and limited Surgical Services procedures to focus efforts on correcting the SPS deficiencies. This inspection focused on the implementation of TJC and NPOSP recommendations; SPS standard operating procedures (SOPs), training, competence, and staffing; surgical cancellations and outsourcing to the community; patient safety and undue burden; and surgical and post-operative infection rates. The OIG team identified additional concerns related to leaders’ decision-making and actions, how the current infrastructure (specifically aging buildings) impacted remediation, and the residency program. The OIG made two recommendations to the Veterans Integrated Service Network Director related to oversight of timely completion of the OIG’s recommendations and hiring actions. The OIG made nine recommendations to the System Director related to inclusion of operating room, surgery, and SPS clinical leaders in remediation efforts; an action plan to establish communication, foster collaboration, and restore trust in system leaders; oversight for the timely completion of pending projects impacting Surgical Services; the development, review, and revision of SOPs and a sustainable SOP maintenance process; SPS staff training and competencies; SPS staffing plan maintenance; readiness evaluation of supplies and equipment prior to anesthetizing a patient; evaluation of the impact and identified needs of the residency programs; and collaboration between the System and Veterans Integrated Service Network 1 Director.